The debate over Medicaid expansion and cooperation with the health insurance marketplaces continues. These two provisions are key to the successful implementation of health insurance reform under the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) and the Health Care and Education Reconciliation Act (HCERA) (P.L. 111-152). Although some Republican governors reluctantly decided that Medicaid expansion was in their states’ best interests, other members of their own party are determined to see PPACA fail regardless of cost.

Republican Arizona Governor Jan Brewer has campaigned for expansion for months with little success. As the legislature debated on May 16, 2013, two leaders from her party legislators brought up competing proposals. Senate President Andy Biggs’ bill would direct the state’s Medicaid agency, the Arizona Health Care Cost Containment System (AHCCCS) to apply for an extension of its existing waiver, which provides coverage to a limited number of adults with incomes at or below the federal poverty level (FPL). It also would appropriate about $135 million for services to childless adults. If the waiver extension is not approved, Biggs suggests funding care for the existing number of childless adults, but not expanding it, and paying for it with the state’s rainy day fund. Brewer, on the other hand, says that fund should be saved for a rainy day.

House Speaker Andy Tobin would put the question to the voters. It is reported that his bill would require a constitutional amendment to implement Medicaid expansion and stop the expansion if either federal funding or state revenue is insufficient. Yet another proposal would simply drop the existing benefits for childless adults, causing about 60,000 people to lose their coverage. Brewer calls that alternative “morally repugnant.” The debate is expected to be contentious. And Arizona can’t pass a budget until it is resolved.

The Florida legislature ended the session without passing any legislation on the Medicaid expansion. So the debate there is over for the year unless Governor Scott calls a special session. One interesting wrinkle in the argument might be worthy of attention. The House Republicans proposed, as an alternative to the Medicaid expansion, a bill that would have provided for a subsidy for the purchase of limited coverage from a state-operated marketplace for a premium of $25 per month. But the House members are eligible for comprehensive health insurance available to all state employees, for which they pay $8.34 per month for individual coverage, or $30 for family coverage. In 2012, they voted to keep this privilege. It is reported that the Senate voluntarily gave up the discount; now they pay the same premium as rank-and-file state employees: $50 per month for individual coverage or $180 per month for family coverage.

About half the states chose not to establish their own health insurance exchange, now called marketplace, under PPACA. A few have gone even farther down the road of resistance. In Missouri, voters passed a ballot measure that bars the establishment of a state exchange unless either the legislature or the voters have passed a law authorizing it. What’s more, no state employee may “provide resources or assistance of any kind” to the establishment of an exchange by the federal government without statutory authorization unless specifically required to do so under federal law. And any taxpayer has standing to sue to enforce the law.